Should platelet transfusion be given perioperatively or only as a backup in case of bleeding in patients who have stopped taking antiplatelet agents like clopidogrel (Plavix) and aspirin after a recent myocardial infarction?

From the Guidelines

Prophylactic platelet transfusion is not recommended perioperatively for patients who have recently stopped antiplatelet agents like clopidogrel and aspirin after a myocardial infarction, and instead, platelets should be reserved as a backup intervention only if clinically significant bleeding occurs during or after surgery. The most recent and highest quality study, 1, suggests that the decision to transfuse platelets should be based on clinical bleeding rather than laboratory values alone, and should balance bleeding risk against thrombotic risk.

Key Considerations

• The timing of elective surgery should ideally be delayed until after the required antiplatelet therapy duration is complete, typically 6-12 months for dual antiplatelet therapy after MI, depending on stent type and patient risk factors.
• If surgery cannot be delayed, aspirin is often continued throughout the perioperative period while clopidogrel may be discontinued 5-7 days before surgery.
• Prophylactic platelet transfusion carries risks including transfusion reactions, infection transmission, and thrombotic complications, which are particularly concerning in patients with recent MI.
• Transfused platelets may be inhibited by residual antiplatelet medications still in circulation.

Clinical Evidence

• A meta-analysis of four randomized trials and one observational study totaling 2,632 patients undergoing CABG surgery found that patients with a longer interruption of clopidogrel had a lower incidence of re-operation and major bleeding 1.
• The 2022 American College of Chest Physicians clinical practice guideline recommends that platelet transfusion be considered in cardiac surgical patients with perioperative bleeding and thrombocytopenia, but not as a routine prophylactic measure 1.
• The AABB clinical practice guideline from 2015 also recommends that platelet transfusion be withheld in nonbleeding surgical patients when the platelet count is greater than 50 × 10^9 cells/L and there is no evidence of coagulopathy 1.

Recommendations

• Platelet transfusion should be reserved as a backup intervention only if clinically significant bleeding occurs during or after surgery.
• The decision to transfuse should be based on clinical judgment, taking into account the patient's individual risk factors and the potential benefits and risks of platelet transfusion.

From the FDA Drug Label

Thienopyridines inhibit platelet aggregation for the lifetime of the platelet (7 to 10 days), so withholding a dose will not be useful in managing a bleeding event or the risk of bleeding associated with an invasive procedure Because the half-life of clopidogrel’s active metabolite is short, it may be possible to restore hemostasis by administering exogenous platelets; however, platelet transfusions within 4 hours of the loading dose or 2 hours of the maintenance dose may be less effective.

The decision to give platelet transfusion perioperatively or only as a backup in case of bleeding should be made on a case-by-case basis. However, based on the available information, it is recommended to consider platelet transfusion as a backup option in case of bleeding, rather than administering it perioperatively as a routine measure. This is because the half-life of clopidogrel's active metabolite is short, and platelet transfusions may be less effective if administered too close to the time of clopidogrel dosing 2. Key considerations include:

• The patient's individual risk of bleeding
• The timing of the last clopidogrel dose
• The availability of platelet transfusions in case of emergency.

From the Research

Platelet Transfusion in Perioperative Period

• The decision to give platelet transfusion perioperatively or only as a backup in case of bleeding in patients who have stopped taking antiplatelet agents like clopidogrel and aspirin after a recent myocardial infarction depends on various factors.
• According to 3, platelet transfusion should only be given when overt bleeding is observed, suggesting that it should not be used prophylactically.
• Similarly, 4 recommends that platelets should not be transfused prophylactically, but only to those few patients with abnormal bleeding thought to be related to the persisting effect of antiplatelet therapy.

Management of Antiplatelet Agents

• The management of antiplatelet agents in the perioperative period is crucial to balance the risk of bleeding and thrombosis.
• 5 suggests that discontinuation of clopidogrel three days prior to surgery demonstrates a similar blood loss pattern compared to a control group, indicating that stopping antiplatelet agents before surgery may reduce the risk of bleeding.
• However, 6 proposes that patients on antiplatelet drugs should continue their treatment throughout surgery, except when bleeding might occur in a closed space, highlighting the importance of weighing the risks of bleeding and thrombosis.

Specific Considerations

• In patients receiving ticagrelor, platelet transfusion and desmopressin administration may have little to no hemostatic effect, as reported in 7.
• The use of antiplatelet agents, such as aspirin and clopidogrel, increases the risk of bleeding, but the risk of thrombosis associated with their discontinuation must also be considered, as noted in 3 and 6.